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Page 2 of 13 Climent et al. Mini-invasive Surg 2018;2:45 I http://dx.doi.org/10.20517/2574-1225.2018.62

Table 1. Classification of post-operative complications according to Clavien-Dindo
Grade Definition
I Any deviation from the normal postoperative course without the need for pharmacological treatment or
surgical, endoscopic, and radiological interventions
II Requiring pharmacological treatment with drugs other than such allowed for grade I complications
III Requiring surgical, endoscopic or radiological intervention
IIIa Intervention not under general anaesthesia
IIIb Intervention under general anaesthesia
IV Life-threatening complication, requiring IC/ICU management
IVa Single organ dysfunction (including dialysis)
IVb Multiorgan dysfunction
V Death of patient
IC: intermediate care; ICU: intensive care unit

EARLY POSTOPERATIVE COMPLICATIONS
[1,8]
Morbidity rates occurred within 30 days of the LAR ranged from 25%-32% while mortality during the
same period reaches 6% to 8% .
[5,8]
Surgical site infection
Surgical site infection (SSI) includes incisional or wound infection and organ space infection occurring
within 30 days after surgery.

Incisional SSI
[10]
Incisional SSI is further divided by the Centres for Disease Control and Prevention into superficial
incisional SSI, involving only the skin and subcutaneous tissue, and those involving deeper soft tissues,
known as deep incisional SSI. Wound infection is defined by the presence of purulent drainage from the
superficial incision with organisms isolated on its culture and signs or symptoms suggestive of infection,
such as erythema, induration and pain. Superficial SSI is one of the most common complications after
[1,2]
anterior resection, being described in 6%-10% of cases . A multivariate analysis showed that wound
[11]
infection was related to tumour stage, a converted laparoscopic procedure and open surgery . The use of
2% chlorhexidine gluconate in 70% isopropyl alcohol skin preparation before surgery may reduce the rate
of SSI in clean-contaminated surgery compared to povidone-iodine, supported data from two systematic
reviews and meta-analysis, albeit with limitations in data interpretation due to heterogeneity [12,13] .

Organ space SSI
Organ space SSI includes anastomotic leakage (AL) and any intra-abdominal or pelvic abscess diagnosed
with radiological examination or reoperation, with the presence of purulent discharge from a drain,
confirmed by laboratory culture. This broad definition makes its interpretation and comparison between
series of patients difficult, with the uncertainty of whether a pelvic abscess occurs in the presence of, or
[11]
absence of, anastomotic insufficiency .
The rate of intra-abdominal or pelvic sepsis after rectal cancer resection varies between series, but is
generally accepted to occur in between 12%-17% of patients [14,15] . In the presence of a localized abscess, a
percutaneous computed tomography (CT)-guided drain placed in interventional radiology combined with
intravenous antibiotics is the cornerstone of management. Transrectal or transperineal ultrasound-guided
[16]
drainage may also be utilized for pelvic sepsis in the presence of a low anastomotic leak . Where an
abscess is not suitable for percutaneous drainage or there is an absence of radiological expertise, surgical
[8]
lavage should be considered, which can be facilitated laparoscopically with good control of sepsis .

Anastomotic leak
The most common postoperative complication after LAR is AL, with an incidence of 5.5%-8% with
[1,3]
significant impact on morbidity and mortality . There is a wide variability in the terminology used in